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Domiciliary treatment of osseo-articular tubercle
546
TUBERCLE
[September, 1923
in deep inspiration, intrapulmonary pressure will alter and so intrapleural pressure will also be affected. Intrapleural pressure, according to West, in Clifford Allbutt's " System of Medicine," is a resultant of the elasticity of the lung, the rigidity of the chest wall , and the movements of respiration. The variation of pressure in different sites of the chest when explored is admitted . From physiological considerations such variations cannot be estimated with mathematical exactitude. From a physical point of view, the pressure actually registered by the distal manometer (D) of the head of water in a kinetic condition is less than its absolute value in a static condition. The higher the distal manometer pressure, the greater will be the difference. This can be shown by screwing the regulator or closing the needle with the end of the finger. Poynting and Thomson state that when liquid flows through a cylinder and displaces gas through a small tube, the pressure head of the liquid not, . only drives the liquid against resistance due to viscosity, but it has to communicate velocity, and therefore kinetic energy to the liquid . Part of the pressure head is therefore used to set the liquid in motion. According to the same authority, viscosity is an important factor. Raising of temperature increases the viscosity of gas and dim inishes that of liquids. The temperature of intrapleural space is considerably higher than the varying external temperature. From our experiments we have seen that, apart. from t ypical visual indications with two manometers, intrapleural pressures, deduced from mathematical fornrul re, are not rel iable. Other empirical methods to estimate intrapleural pressures during flow of fluid have been tried and found wanting. The static method we advocate for estimating intrapleural pressure any time during the operation is easy for practical work and is reliable. In the static method, the fact that the two manometers (instead of one) give the same reading is some advantage. In our experience with our technique and controlled rate of flow, pleural effusion during pneumothorax treatment is a rarity. 'Ve have no doubt. the advantages pointed out will in future popular ise a two-manometer pattern for routine use. The ordinary single manometer pattern can easily be altered. We support the view that fixed patterns with squeezi~g rubber bags are not safe for the beginner or for routine work. 'Ve avoid high distal manometer pressure, gas being allowed to flow into the chest. at first by suction.
DOMICILIARY TREATMEKT OF OSSEO-AHTICULAR TUBERCLE. 1 By W. C. RIVERS, M.R.C.S., D .P.H. Tuberculosis Officer, Barnsletj District, lVe8t Ridinll, Yorks.
IN the summer of 1919 I spent two months working at Alton, and thereafter Ior tw o years tried conservative treatment in dispensary practice; publishing in the Lancet in December, 1921, an account of 22 new cases, more than two-thirds of whom had been dealt with throughout at home. Of these latter, nearly an eighth had discarded apparatus and were 1
I'np or read li t Bristol Meeting of the 'I'uberculosia Society, March 16, 1923.
September, 1923]
'l'REATMENT OF OSSEO-ARTICULAR TUBERCLE
547
recovered j in over 60 per cent, the disease had become quiescent ; whilst in only about 30 per cent.-all adults, by the way, for whom institutional treatment is most difficult to procure-did it remain active. There were no deaths, but two patients, in whom, when first seen, disease was already well established, were going downhill. I have now to bring these figures up to date. The new cases have extended to 38, of whom 31, or over 80 per cent., were treated at their homes. The improvement is due to one getting earlier cases , as the general practitioner partially becomes weaned from the bad old plan of ambulant general hospital treatment. Of the 31, n ine have discarded apparatus and returned to school or to work; twelve are up and about in celluloid splints, or in one or two instances in plaster; six are in bed, on extension apparatus; one has relapsed, and is about in a plaster ; while
Righ t (affected) hip .
FIG. I.
Left (norma.l) hip.
the two moribunds aforement.ioned have duly died, with another in whom the bone disease was not much more than an incident in the course of acute phthisis. The homes in question have been ordinary working-class dwellings, and by far the longest time in bed has been one year five days; this was in a back-to-back house, and the patient when first sent to me had a two-year history of hospital treatment. He had also an acutely tuberculous hip, badly flexed and adducted with a large septic abscess, and in the other leg tuberculous disea se of the tibia. He was over age for Alton or Leasowe. Now all the lesions have healed, the hip is in good position, and he is about in a celluloid splint. Diagnosis has been under X-ray control; and to meet the possible objection that some of the cases may not have been true tuberculosis I could show two skiagrams of a not over common condition liable to be mistaken for true morbus c OX aJ. viz., Perthes' disease or pseudo-coxalgia j because if from a rather shalt
548
TUBERCLE
[September, 1923
series of osseo-articular tubercle a rare form of non-tuberculous arthritis has been twice separated off, it is not likely tha.t elementary mistakes in diagnosis have been made. One of these skiagrams, given above, perhaps deserves further mention, because it is of a very early case, and such pictures are needed in a disease still in many respects obscure. In no skiagram that I have seen in the literature is there such slight flattening of the epiphysis of the femoral head, and yet the femoral neck is already greatly thickened. To return: .we put the patient to begin with in bed next an open. window, and since working-class furniture is mostly rubbish (being made primarily not for use, but to bring in a. profit to the manufacturer and retailer) I have just lately designed a "trestleboard." This will serve
FIG.
2.-Child with right-sided m01"bus coxa on extension in .. trestleboard,"
for hip, spine, or knee affections, and being complete in itself saves the tuberculosis officer's time. The foot end is high, so as to take the weight of the bedclothes off the feet: also perforated in six rows, in order to transmit the cord carrying the weight in any extension for hip or knee. There are two hinged wooden flaps, that can be raised to any degree, to support either leg in flexion of the hip. There are two wooden rods running from head to foot, to which to secure either (sound) leg in hip disease, so as to keep the patient in good position; or, in spinal disease, to both of which to fasten the jean jacket keeping the patient recumbent and keeping him also from falling out when the board is .. tilted" preparatory to taking a cast for a spinal jacket. The height of the board is such that the child can look ant of window without raising himself. Its height also saves the mother stooping when she attends to the child. As to length. any patient can be taken up to 5 ft . 4 in. tall. The legs are folding, while handles at head and foot facilitate carriage out of doors for heliotherapy and a quick return if rain falls. All the patient's friends are asked for is a flat-iron as weight and two bricks to raise the foot end; and these are, of course, unnecessary in spinal disease.
September. 1923]
TREATMENT OF OSSEO-ARTICULAR TUBERCLE
549
Practice soon makes easy the subsequent construction of celluloid splints. Moreover, as has been found at Carshalton, leather binding for the edges is not essential, whilst the application of intermediate coats of an acetone solution of celluloid made very thick-about the consistency of melting hardbake-saves time, muslin and work. In a letter received since this paper was read, Sir Henry Gauvain has been good enough to write: "The more I see of it the more I am convinced that there is a great scope for extension of work by tuberculosis officers on your lines." Those lines are obvious enough, however. A good number of tuberculosis officers have now had some experience at Alton. To such I would say, try this domiciliary treatment of bone and joint tubercle as I did at first, namely, as preparatory during the wait for institutional treatment, and you will find most times that the child need never go away at all. Moreover, you will find also that it will help you with those very important persons, our feeders the general practitioners. The yearly increase in my new patients, or rather examinees, who in 1922 numbered 730 on a population of 120,000, has undoubtedly been furthered by one having lessened one's ignorance of surgical tubercle. As my friend Dr. J. B. McDougall has rightly said, the general practitioner judges a tuberculosis scheme by nothing so much as the tuberculosis officer's clinical competence. My colleague, Dr. Crowley of Harrogate, is now making splints in his district, and probably another West Riding tuberculosis officer will begin soon. Last, and unfortunately not least, there is the consideration of economy. Naturally it comes far cheaper to treat patients at their homes than to send them away. What counts too is that it comes cheaper to treat them at once. This home treatment of bone and joint tubercle can be started immediately, thus preventing sinuses and chronicity with eventual crippling, or death in the workhouse infirmary. We have here an example of the truth of an observation by a recent American student' of European sickness insurance, that the fact is that prevention and treatment of diseases are usually inseparable." II
HEALTH WEEK. The movement known 8$ Health Week was instituted in 1912 with undonbted advantage to the haalbh of the community, and in 1914, at the request of a meeting of local anthorities, the Royal Sanitary Institute appointed a committeeto undertake the organisation. The object of Health Week is to focus pnblic attention for one week in the year on matters of health, and to arouse that sense of personal respons ibility for health without which all public work, whether by Government or local authorities, must fall far short of its aims. Health week this year is to be held from Octobe·r 7 to 13, and it is proposed that the dominant idea for 1923. should be II Self Help
I
in Health." The suggested programme includes :Sermons in churches and chapels. Lessons in sunday schools and in day schools; health talks at factories, clubs, mothers' meetings, literary and other societies, co-operative and friendly societies, &0.; lantern lectures and cinematograph shows; lectures in town halls and municipal buildings i health .e~bibitions ; baby competitions; visits to muu icipal wo~ks, disinfecting stations. water works! cleansing stations schools for mothers, hospitals, open. air scho~ls &c.· demonstrations or exhibitions of, home 'nursing, housewifery, infant care, physical culture, Morris dancing.
Gerald Morgan: Public Relief of Sickness.
London, 1923, p. 21.
TUBERCLE
[September, 1923
in deep inspiration, intrapulmonary pressure will alter and so intrapleural pressure will also be affected. Intrapleural pressure, according to West, in Clifford Allbutt's " System of Medicine," is a resultant of the elasticity of the lung, the rigidity of the chest wall , and the movements of respiration. The variation of pressure in different sites of the chest when explored is admitted . From physiological considerations such variations cannot be estimated with mathematical exactitude. From a physical point of view, the pressure actually registered by the distal manometer (D) of the head of water in a kinetic condition is less than its absolute value in a static condition. The higher the distal manometer pressure, the greater will be the difference. This can be shown by screwing the regulator or closing the needle with the end of the finger. Poynting and Thomson state that when liquid flows through a cylinder and displaces gas through a small tube, the pressure head of the liquid not, . only drives the liquid against resistance due to viscosity, but it has to communicate velocity, and therefore kinetic energy to the liquid . Part of the pressure head is therefore used to set the liquid in motion. According to the same authority, viscosity is an important factor. Raising of temperature increases the viscosity of gas and dim inishes that of liquids. The temperature of intrapleural space is considerably higher than the varying external temperature. From our experiments we have seen that, apart. from t ypical visual indications with two manometers, intrapleural pressures, deduced from mathematical fornrul re, are not rel iable. Other empirical methods to estimate intrapleural pressures during flow of fluid have been tried and found wanting. The static method we advocate for estimating intrapleural pressure any time during the operation is easy for practical work and is reliable. In the static method, the fact that the two manometers (instead of one) give the same reading is some advantage. In our experience with our technique and controlled rate of flow, pleural effusion during pneumothorax treatment is a rarity. 'Ve have no doubt. the advantages pointed out will in future popular ise a two-manometer pattern for routine use. The ordinary single manometer pattern can easily be altered. We support the view that fixed patterns with squeezi~g rubber bags are not safe for the beginner or for routine work. 'Ve avoid high distal manometer pressure, gas being allowed to flow into the chest. at first by suction.
DOMICILIARY TREATMEKT OF OSSEO-AHTICULAR TUBERCLE. 1 By W. C. RIVERS, M.R.C.S., D .P.H. Tuberculosis Officer, Barnsletj District, lVe8t Ridinll, Yorks.
IN the summer of 1919 I spent two months working at Alton, and thereafter Ior tw o years tried conservative treatment in dispensary practice; publishing in the Lancet in December, 1921, an account of 22 new cases, more than two-thirds of whom had been dealt with throughout at home. Of these latter, nearly an eighth had discarded apparatus and were 1
I'np or read li t Bristol Meeting of the 'I'uberculosia Society, March 16, 1923.
September, 1923]
'l'REATMENT OF OSSEO-ARTICULAR TUBERCLE
547
recovered j in over 60 per cent, the disease had become quiescent ; whilst in only about 30 per cent.-all adults, by the way, for whom institutional treatment is most difficult to procure-did it remain active. There were no deaths, but two patients, in whom, when first seen, disease was already well established, were going downhill. I have now to bring these figures up to date. The new cases have extended to 38, of whom 31, or over 80 per cent., were treated at their homes. The improvement is due to one getting earlier cases , as the general practitioner partially becomes weaned from the bad old plan of ambulant general hospital treatment. Of the 31, n ine have discarded apparatus and returned to school or to work; twelve are up and about in celluloid splints, or in one or two instances in plaster; six are in bed, on extension apparatus; one has relapsed, and is about in a plaster ; while
Righ t (affected) hip .
FIG. I.
Left (norma.l) hip.
the two moribunds aforement.ioned have duly died, with another in whom the bone disease was not much more than an incident in the course of acute phthisis. The homes in question have been ordinary working-class dwellings, and by far the longest time in bed has been one year five days; this was in a back-to-back house, and the patient when first sent to me had a two-year history of hospital treatment. He had also an acutely tuberculous hip, badly flexed and adducted with a large septic abscess, and in the other leg tuberculous disea se of the tibia. He was over age for Alton or Leasowe. Now all the lesions have healed, the hip is in good position, and he is about in a celluloid splint. Diagnosis has been under X-ray control; and to meet the possible objection that some of the cases may not have been true tuberculosis I could show two skiagrams of a not over common condition liable to be mistaken for true morbus c OX aJ. viz., Perthes' disease or pseudo-coxalgia j because if from a rather shalt
548
TUBERCLE
[September, 1923
series of osseo-articular tubercle a rare form of non-tuberculous arthritis has been twice separated off, it is not likely tha.t elementary mistakes in diagnosis have been made. One of these skiagrams, given above, perhaps deserves further mention, because it is of a very early case, and such pictures are needed in a disease still in many respects obscure. In no skiagram that I have seen in the literature is there such slight flattening of the epiphysis of the femoral head, and yet the femoral neck is already greatly thickened. To return: .we put the patient to begin with in bed next an open. window, and since working-class furniture is mostly rubbish (being made primarily not for use, but to bring in a. profit to the manufacturer and retailer) I have just lately designed a "trestleboard." This will serve
FIG.
2.-Child with right-sided m01"bus coxa on extension in .. trestleboard,"
for hip, spine, or knee affections, and being complete in itself saves the tuberculosis officer's time. The foot end is high, so as to take the weight of the bedclothes off the feet: also perforated in six rows, in order to transmit the cord carrying the weight in any extension for hip or knee. There are two hinged wooden flaps, that can be raised to any degree, to support either leg in flexion of the hip. There are two wooden rods running from head to foot, to which to secure either (sound) leg in hip disease, so as to keep the patient in good position; or, in spinal disease, to both of which to fasten the jean jacket keeping the patient recumbent and keeping him also from falling out when the board is .. tilted" preparatory to taking a cast for a spinal jacket. The height of the board is such that the child can look ant of window without raising himself. Its height also saves the mother stooping when she attends to the child. As to length. any patient can be taken up to 5 ft . 4 in. tall. The legs are folding, while handles at head and foot facilitate carriage out of doors for heliotherapy and a quick return if rain falls. All the patient's friends are asked for is a flat-iron as weight and two bricks to raise the foot end; and these are, of course, unnecessary in spinal disease.
September. 1923]
TREATMENT OF OSSEO-ARTICULAR TUBERCLE
549
Practice soon makes easy the subsequent construction of celluloid splints. Moreover, as has been found at Carshalton, leather binding for the edges is not essential, whilst the application of intermediate coats of an acetone solution of celluloid made very thick-about the consistency of melting hardbake-saves time, muslin and work. In a letter received since this paper was read, Sir Henry Gauvain has been good enough to write: "The more I see of it the more I am convinced that there is a great scope for extension of work by tuberculosis officers on your lines." Those lines are obvious enough, however. A good number of tuberculosis officers have now had some experience at Alton. To such I would say, try this domiciliary treatment of bone and joint tubercle as I did at first, namely, as preparatory during the wait for institutional treatment, and you will find most times that the child need never go away at all. Moreover, you will find also that it will help you with those very important persons, our feeders the general practitioners. The yearly increase in my new patients, or rather examinees, who in 1922 numbered 730 on a population of 120,000, has undoubtedly been furthered by one having lessened one's ignorance of surgical tubercle. As my friend Dr. J. B. McDougall has rightly said, the general practitioner judges a tuberculosis scheme by nothing so much as the tuberculosis officer's clinical competence. My colleague, Dr. Crowley of Harrogate, is now making splints in his district, and probably another West Riding tuberculosis officer will begin soon. Last, and unfortunately not least, there is the consideration of economy. Naturally it comes far cheaper to treat patients at their homes than to send them away. What counts too is that it comes cheaper to treat them at once. This home treatment of bone and joint tubercle can be started immediately, thus preventing sinuses and chronicity with eventual crippling, or death in the workhouse infirmary. We have here an example of the truth of an observation by a recent American student' of European sickness insurance, that the fact is that prevention and treatment of diseases are usually inseparable." II
HEALTH WEEK. The movement known 8$ Health Week was instituted in 1912 with undonbted advantage to the haalbh of the community, and in 1914, at the request of a meeting of local anthorities, the Royal Sanitary Institute appointed a committeeto undertake the organisation. The object of Health Week is to focus pnblic attention for one week in the year on matters of health, and to arouse that sense of personal respons ibility for health without which all public work, whether by Government or local authorities, must fall far short of its aims. Health week this year is to be held from Octobe·r 7 to 13, and it is proposed that the dominant idea for 1923. should be II Self Help
I
in Health." The suggested programme includes :Sermons in churches and chapels. Lessons in sunday schools and in day schools; health talks at factories, clubs, mothers' meetings, literary and other societies, co-operative and friendly societies, &0.; lantern lectures and cinematograph shows; lectures in town halls and municipal buildings i health .e~bibitions ; baby competitions; visits to muu icipal wo~ks, disinfecting stations. water works! cleansing stations schools for mothers, hospitals, open. air scho~ls &c.· demonstrations or exhibitions of, home 'nursing, housewifery, infant care, physical culture, Morris dancing.
Gerald Morgan: Public Relief of Sickness.
London, 1923, p. 21.